Photo by lucasreddingerDespite the well-documented benefits of harm reduction approaches to HIV prevention, particularly among injection drug users (IDUs), service coverage is abysmally low throughout Asia.

With about 30% of new HIV infections in the region associated with drug use, there is a very real and urgent need to scale-up harm reduction services. This is one of many issues being discussed by delegates at the first Asian Consultation on the Prevention of HIV Related to Drug Use being held this week in Goa.

“Injecting drug use has acted as a catalyst for HIV epidemics at the onset of the pandemic in many Asian countries. The sharing of injection equipment is a very efficient way to transmit HIV from one person to the next,” Dr JVR Prasada Rao, Director of the Regional Support Team of the Joint United Nations Programme on HIV/AIDS (UNAIDS), said during the consultation.

“Once HIV enters the IDU network, it spreads very rapidly and an injecting drug use-related HIV epidemic kicks off in a country. This is what happened in China, Indonesia, Viet Nam and the north-east of India.”

With HIV prevalence rates of between 20 and 85% among IDUs in some Asian countries, governments have no excuse for not responding to the issue by integrating harm reduction approaches into HIV prevention and treatment programmes and scaling up interventions.

“Injecting drug use is increasing in many parts of [India] and its association with HIV is well documented,” said Dr Sujatha Rao, director-general of the National AIDS Control Organization (NACO) in India. But harm reduction approaches to HIV prevention, treatment and care are not being scaled up, even in India.

“About 3000 IDUs are receiving OST [opioid substitution therapy] in India,” Dr Sujatha Rao told a Key Correspondent during an interview on the sidelines of the Goa consultation, adding that “more than 40,000 IDUs may need to be put on OST in India.”

Although the World Health Organization (WHO) list of essential medicines includes both methadone and buprenorphine – commonly used opiate substitution drugs – many countries in Asia continue to list these drugs as illegal. India is one of them and methadone is still illegal in the country. “A policy stand on OST is yet to be taken,” Dr Sujatha Rao said.

Buprenorphine is legally available in India, Pakistan and Nepal. Methadone is legally available in only five Asian countries: China, Hong Kong, Indonesia, the Lao People’s Democratic Republic and Myanmar.

“The priority now is to see that all countries that report injecting drug use make methadone legal, include it in the list of essential drugs and expand access to drug substitution treatment,” said Dr Prasada Rao of UNAIDS.

Legal reforms that support policies for HIV prevention, treatment and care for communities at risk, especially IDUs, are another pressing need. The criminalization of injecting drug use has made it harder to reach many communities at risk of HIV infection. The revision of laws criminalizing injecting drug use is clearly vital, not only to improve HIV responses in the region but also to ensure the achievement of Universal Access targets by 2010.

All 189 signatories to the Declaration of Commitment at the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS, further committed in 2006 to expand harm reduction services to 80% of the IDU population by 2010. Currently, these services reach about 3% of those in need.

“It is riskier to access HIV prevention, treatment and care services for IDUs than to get illegal drugs,” one delegate at the Goa consultation said.

Harm reduction approaches to HIV prevention, treatment and care need to be scaled up significantly and rapidly. Without decisive action, it is not clear how Asian countries can achieve this.

Photo by Hi yAAvA HiFor the first time in Asia, AIDS experts, parliamentarians, civil society and drug user organisations have gathered together for a consultation on HIV prevention and treatment for drug users.

Organised by the Asian Consortium on Drug Use, HIV, AIDS and Poverty, the consultation is being attended by more than 400 delegates from 27 countries with the aim of addressing the political, legal and social barriers to HIV interventions for injecting drug users (IDUs).

Delegates are also expected to advocate for the types of expanded harm reduction programs promoting drug substitution treatment, needle and syringe exchanges and peer education projects that have proven effective in stemming the spread of HIV.

The Joint United Nations Programme on HIV and AIDS (UNAIDS) estimates that 30 percent of all new infections worldwide, excluding in Africa, are associated with injecting drug use. Nearly half of the world's estimated 13 million drug users live in Asia where injecting drug use is a major factor fuelling HIV transmission.

Most of the global supply of opium and heroin is produced in Asia where vulnerable groups who inject drugs form a significant percentage of people engaged in high-risk behaviours such as sharing contaminated injecting equipment and unprotected sex.

Some Asian countries have reported HIV prevalence rates as high as 85 percent among IDUs while others that had previously reported few or no cases of HIV in IDUs have now detected the virus among some users.

"We will address the vulnerability related to drug use and HIV and AIDS affecting millions of people in Asia and the related social hazards including criminalisation, incarceration and their linkages to poverty," said Luke Samson, Co-Chair of the consultation and Executive Director of the New Delhi-based advocacy group SHARAN.

Across the region, the criminalisation of drug use, severe stigma and discrimination and law enforcement practices that marginalise and penalise drug users have driven them underground and deterred them from accessing life-saving HIV prevention and treatment services.

Gary Lewis, Representative of the United Nations Office on Drugs and Crime (UNODC), stressed at the conference that successful models of community-based HIV prevention through outreach and counselling needed to be adopted if HIV was to be addressed as a social as well as a public health issue.

"In Asia, the need of the hour is to scale-up interventions to reach out to populations at risk and to save lives. We know what to do, but we need to do more of it," Lewis said.

Delegates at the consultation will review the alarming spread of HIV in prison and custodial settings and advocate for reformed legislations, engagement with law enforcement and narcotics agencies and national AIDS policies that allow services to access incarcerated people and those in compulsory rehabilitation programs.

"We must ensure access to prevention and treatment services and protect the rights of the most at risk populations, such as people who inject drugs by involving them and their communities in every stage of the AIDS response," said UNAIDS Asia Pacific Regional Director, Prasada Rao.

The consultation also aims to engage key players from the governmental, corporate and civil society sectors in attempts to define an Asia-specific HIV prevention and treatment strategy in order to achieve universal access to treatment for people injecting drugs.

"Regional collaboration for HIV preventions is the most effective mechanism to combat the growing pandemic. This consultation is a unique opportunity to generate enduring solutions to HIV and AIDS issues affecting drug users across Asia," said Shri Oscar Fernandes, Minister of State for Labour and Employment and Convener Parliamentary Forum on HIV and AIDS.

Photo by bobbyramakantThe absence of coherent national and regional policies to support HIV harm reduction programs in Asian countries hit hard by injecting drug use is acute and limits the likelihood of these countries achieving ‘Universal Access’ targets by 2010.

Under these circumstances, it can be incredibly difficult for pharmaceutical companies to procure the raw materials needed for drugs that are classified as narcotics in many countries and manufacture and supplying these drugs to countries with non-supportive policies.

“The biggest impediment once the opioid substitution therapy (OST) or needle syringe exchange program concept has been accepted by the medical and NGO fraternity is the police and home office and the International Narcotics Control Board (INCB),” Dr Saxeena said.

“Since both the essential drugs—methadone and buprenorphine—fall under the narcotic category, the internal ministry exercises such controls and delays in granting the clearances and quotas, which in turn delays the treatment provision by years.”

OST and needle syringe exchange programs are both accepted and promoted by WHO and methadone and buprenorphine are included on the organisation’s list of essential medicines since 2005. Yet in the majority of Asian coutrnies, these medicines remain illegal.

“The internal ministry has the task to cut down the supply of drugs of abuse, catch the drug peddlers,” said Dr Saxena, adding that the ministry should not interfere in well-established treatment protocols for injecting drug users (IDUs).

“The internal ministry should facilitate treatment because it helps in reducing street crimes and costs related to judicial procedures,” said Dr Saxena.

Another grave issue is the intermittent supply of substitution drugs. In Nepal, a methadone program was started but due to supply problems many NGOs and IDUs became reluctant to continue with the process.

In Myanmar, a single supply of methadone was provided by WHO’s India office, which lasted for just three to four months. In India, EU funding for OST programs in five cities dried out and the projects only survived after the government stepped in.

The capacity of civil society groups, particularly community-based organisations comprised of IDUs, needs to be built up to help facilitate the rapid scale-up of harm reduction programs. Drug user involvement in planning and designing such interventions as well as their deployment and evaluation is essential to ensure that such interventions meet the needs to targeted clients.

There are lessons to be learnt from TB drug-supply protocols. Different stakeholders need to sit down with pharmaceutical companies and come up with long-term bulk order systems to supply drugs to a certain region for a pre-agreed price.

Like the European Union, other regions such as South Asia, Southeast Asia, the South Asian Association for Regional Cooperation (SAARC) and or Central Asia, should come up with a regional registration procedure which should be respected by all countries. This would expedite the scale-up of OST programs, according to Dr Saxena.

Fortunately, the UN Regional Task Force on Injecting Drug Use and HIV/AIDS in Asia and the Pacifric has recently published a guide for miproving procurement procedures of such essential medicines in the region (see http://www.unodc.un.or.th/drugsandhiv/publications/2007/Step-by-Step.pdf).

As we inch towards the 2010 ‘Universal Access’ targets, it may be helpful not only to be mindful of the concerns of drug-manufacturers but also to learn from other interventions, such as Directly Observed Treatment Short-course (DOTS), which has successfully supplied TB drugs to more than 10 million people.

Photo by bobbyramakantHIV spreads fast once it enters a community of injecting drug users (IDUs). Despite the fact that this is well-documented, some attempts to contain the spread of the epidemic among IDUs have been delayed by up to 20 years.

In some Asian countries, such as Thailand, Myanmar, Cambodia and in four Indian states, there is evidence to suggest that HIV incidence is declining. But the number of HIV-positive IDUs in the same countries hasn’t dropped. In some places, it has increased.

After HIV was first found in IDUs in Thailand, the incidence of the disease went up from zero to 45 percent in less than a year. Once HIV was detected in IDUs in India’s Manipur state incidence rates shot up to 50 percent in six months.

Although it has been clear for some time that HIV spreads quickly among IDUs, responses to the growing epidemic have been too slow to avert the tide of IDU-related HIV, Dr Swarup Sarkar, from the Asian Development Bank, told delegates at the Asian Consultation on Prevention of HIV Related to Drug Use in Goa this week.

While the first case of HIV in Thailand was reported in 1987 there are still no comprehensive harm reduction programs in the country. In Myanmar, the first case of HIV was reported in 1988, but it took another 16 years for harm reduction projects to be implemented and most remain funded by external donor agencies. In Manipur, it took 20 years for a government-funded comprehensive harm reduction responses to the crisis to be developed.

Of the 10 Asian countries that have reported being home to IDUs, only six or seven have needle or syringe exchange programs, just three have opioid substitution therapy programs (OST) and only five or six have peer education programs in place.

“In China, because of the urban-rural divide, people who have access to OST don’t have access to needle syringe exchange programs,” said Dr Sarkar.

In Malaysia, comprehensive harm-reduction programs have been operating for the past two to three years but less than 10 percent of IDUs are being reached. OST coverage in Malaysia might be slightly higher but the reach of syringe exchange and peer education programs is very low.

“In Bangladesh, Pakistan, parts of Malaysia, China and India, and few other Asian countries there is a wonderful opportunity to keep HIV incidence in IDU low [using comprehensive harm reduction responses],” said Dr Sarkar.

The limited involvement of IDUs in program design and implementation is a big impediment to the fight against the spread of HIV. The rift between government policy and harm reduction activities aimed at HIV prevention, treatment and care is also hampering progress.

“At least the service provider and IDUs should be immune to the legal issues”, a delegate at the Goa conference said.

Studies have shown that vertical interventions such as needle and syringe exchange programs or OST result in fewer drops in HIV incidence than combined comprehensive harm reduction approaches.

“If we invest and focus on comprehensive harm reduction responses for IDUs, we can avert a large scale HIV epidemic,” said Dr Sarkar.

Needle and syringe exchange programs and OST could potentially prevent up to 80 percent of new HIV infections among IDUs - currently a mandatory national target for governments to achieve before 2010 as part of the Universal Access framework.

All countries in the world need to scale up the cost-effective, proven and WHO recommended strategies to reduce the number of deaths attributed to tobacco use. The World Health Statistics Report (2008) of WHO released 10 days before this year's World No Tobacco Day (31 May) ups the urgency to scale up quality interventions to control tobacco use.

About half of all countries in the world implement none of the recommended tobacco control policies, despite the fact that tobacco control measures are cost-effective and proven. Moreover, not more than 5% of the world's population is fully covered by any one of these measures.

World Health Statistics Report (2008) had further confirmed that heart disease, obesity, and tobacco use were among the leading causes of deaths worldwide. The number of deaths from non-communicable chronic conditions, the risk to which is exacerbated by tobacco use, is alarmingly rising far more than the number of deaths from communicable diseases like HIV, TB or Malaria.

The single most preventable cause of death world wide, the report stated, is tobacco use. Tobacco use has been found to kill one-third to one-half of its users, according to this report.

Earlier in February 2008, WHO had released the World Tobacco Epidemic Report which underlines not only the evidence-based fact that tobacco epidemic is worsening but also recommends a comprehensive package of six-effective tobacco control policies - clubbed as 'MPOWER' that have demonstrated results in helping countries stop the diseases, deaths and economic damages caused by tobacco use.

M: stands for 'monitor' tobacco use and prevention policies. Assessment of tobacco use and its impact must be strengthened.

P: stands for 'protect' people from tobacco smoke. All people have a fundamental right to breathe clean air. Smoke-free places are essential to protect non-smokers and also to encourage smokers to quit.

O: stands for 'offer' help to quit tobacco use. Services to treat tobacco dependence are fully available in only nine countries with 5% of the world's population. Countries must establish programmes providing low-cost, effective interventions for tobacco users who want to quit.

W: stands for 'warn' about the dangers of tobacco use. Despite conclusive evidence, relatively few tobacco users understand the full extent of their health risk. Graphic warnings on tobacco packaging deter tobacco use, yet only 15 countries, representing 6% of the world's population, mandate pictorial warnings (covering at least 30% of the principal surface area) and just five countries with a little over 4% of the world's people, meet the highest standards for pack warnings. More than 40% of the world's population lives in countries that do not prevent use of misleading and deceptive terms such as 'light' and 'low tar'.

E: stands for 'enforce' bans on tobacco advertising, promotion and sponsorship. Partial bans on tobacco advertising, promotion and sponsorship, do not work because the industry merely redirects its resources to other non-regulated marketing channels. Only a total ban can reduce tobacco consumption and protect people, particularly youth, from industry marketing tactics. Only 5% of the world's population currently lives in countries with comprehensive bans on tobacco advertising, promotion and sponsorship.

R: stands for 'raised' taxes on tobacco. Raising taxes and therefore prices, is the most effective way to reduce tobacco use, and especially to discourage young people from using tobacco. Only 4 countries, representing 2% of the world's population, have tax rates greater than 75% of retail price.

"Reversing this entirely preventable epidemic must now rank as a top priority for public health and for political leaders in every country of the world" said Dr Margaret Chan, Director-General of the WHO in the summary.

However the global tobacco epidemic stands starkly apart from other conventional disease control programmes because of an aggressive tobacco industry that is hell-bent on protecting and expanding its markets globally, particularly in the developing countries of Asia and Africa. Tobacco corporations across the world have not only been aggressively protecting and promoting their tobacco markets, particularly in the developing countries, but also trying their best to either abort or weaken the public health policies that begin to take shape in countries around the world.

"Big Tobacco's interference in health policy is one of the greatest threats to the treaty's implementation and enforcement. Philip Morris/Altria, British American Tobacco (BAT) and Japan Tobacco (JT) use their political influence to weaken, delay and defeat tobacco control legislation around the world. While the industry claims to have changed its ways, it continues to use sophisticated methods to undermine meaningful legislation" had said Kathy Mulvey of Corporate Accountability International at the recent meeting last year on the global tobacco treaty - the Framework Convention on Tobacco Control (FCTC).

The alert monitoring of tobacco corporations and holding them accountable for violating existing health policies will further boost the impact of the WHO's recommended MPOWER package in reducing tobacco use globally.

The Gram Pradhans in Miyaganj Block of Unnao District, where a social audit of NREGS is going on presently, have started admitting one after another that the officials take anywhere from 15 to 30% money as commissions before releasing the funds for the works.

First they were complaining about how the workers don't complete their due measurement of work, for example digging 100 cu. ft. of earth, to become eligible for full payment of Rs. 100 per day and how they have to make adjustments.

But when it was pointed out to them that if this was the case then the number of days of work shown on muster roll should have been less than the actual days of work performed. But in panchayat after panchayat a common complaint has been that the workdays of workers are exaggerated on muster rolls as well as on job cards.

The days have been fudged essentially to siphon out money from the accounts of gram panchayats. But the Gram Pradhans are afraid of speaking out openly because the officials will become vindictive towards them if such a complaint was made. This is yet another example of how it is the bureaucracy which dominates and manipulates the people's representatives in our democracy.

Gram Pradhan Hari Prasad of Shirsh Kanhar complained that sometimes the officials withdraw money and the work never gets performed.

It is precisely to prevent the Block level officials like the BDOs, JEs and VDOs from taking out money from the share of the panchayats that a decision has been taken by the government to transfer the money directly from the District to the Gram Panchayat accounts and to open bank accounts for workers for direct transfer into them.Gram Pradhan of Nurullanagar Samim, who is uneducated, today admitted that he just signs wherever he is told to. He works for a powerful family in the village and his Village Development Officer completes all the documents for him. It is quite obvious that the Pradhan of this panchayat is not in control of the affairs here.

Chandrika, the son of Gram Pradhan of Village Panchayat Sindhari Khurd, Smt. Shyama, threatened and misbehaved with the social audit team in his panchayat. According to the villagers no work under NREGS has been performed here.

A major discrepancy found in the muster rolls obtained under RTI Act, was the absence of any financial approval for the works having been shown to be already performed. The villagers had very little knowledge about the Act. In most panchayats the job cards were distributed to the villagers just before the arrival of the social audit teams there. The names of women were missing from the job cards as a result of which women were not able to stake claim to perform work under the scheme. According to NREGA the names of all adult family members desirous of working should be there on the cards.

The name of the Gram Pradhan of Village Panchayat Akbarpur as well as his five brothers and one sister-in-law figured in the recently concluded BPL survery even though the family is quite well off.

The Asha health workers of the Janani Suraksha Yojana today contacted the social audit team on their own initiative and complained about how they were paid only Rs. 450 per delivery as opposed to the stipulated Rs. 600. The beneficiary mother also has to pay Rs. 600-700 to receive her share of Rs. 1400 from the health centre. Even to receive their reduced amounts the women are made to run a number of times by the health centre staff. If one doesn't pay the commission the amount due is not released. Yesterday evening Bina w/o Suresh resident of Hyderabad town area in Unnao Dist. delivered a baby at home because the Miyaganj Primary Health Centre turned her away during the day. One staff at this health centre Pankaj makes the Asha health workers stay till late evening or sometimes night to release their payments causing them inconvenience in returning to their homes.

Dr Sandeep Pandey

[Author is a noted social activist, recepient of Ramon Magsaysay Award (2002) for emergent leadership and heads National Alliance of People's Movements (NAPM) in India]

Photo by bobbyramakantRepeated calls for harm reduction approaches to HIV prevention, treatment and care, particularly for injection drug users (IDUs), were answered with a reality check on the second day of the first Asian Consultation on Prevention of HIV Related to Drug Use, in Goa.

During a session that brought together parliamentarians, civil society activists and IDUs, the voices of several users provided delegates with a stark reminder of the reality on the ground.

“Drug users are treated as criminals, as sub-human beings” said Bijaya Pandey from Nepal.

“For the past few years we have been hearing about ‘3 by 5’ and ‘2010’– please, please, don’t give us a false illusion of hope,” Pandey said, referring to the World Health Organization’s (WHO) failed initiative to provide antiretroviral drugs (ARVs) to three million people by end of 2005, and the promise of universal access to prevention, treatment and care by 2010.

Opioid substitution therapy (OST) and needle syringe exchange programmes are not operating or even legal in some Asian countries. Only a handful of states in the region have government-supported OST or syringe exchange programmes.

The combination of the criminalization of injection drug use and a lack of a coherent legal and policy framework on drugs, means that not only are IDUs are at risk while accessing existing services, but service providers are also at risk of being penalized for offering them.

“Bijaya, Tamara and I are the lucky survivors of the war – the war on drugs,” said Fredy Edi, a board member of the International Network of People who Use Drugs and the Indonesian Drug User Network, referring to IDU representatives Pandey and Tamara Speed from Australia. “The war on drugs is also war on health,” Fredy added.

There is evidence to suggest that ‘war on drugs’ has caused a rise in HIV infections, particularly among IDUs, across the region. The number of new hepatitis C (HCV) infections has also increased since the war on drugs was launched. HCV infection rates are believed to have reached epidemic proportions in many parts of Asia, such as Manipur in India.

“We have buprenorphine but distribution is limited to less than 10% of people who need it,” a delegate from Manipur said during the meeting.

Another delegate raised the issue ARV treatment for IDUs. Many IDUs are reportedly being told that they must stop taking drugs before they can receive treatment from ARV centres.

Delegates also expressed concern over the lack of programmes designed to tackle inhaling drug use and the lack of programmes tailored towards women, transgendered users or the partners of male users.

“It is very difficult to find female drug users in public spots,” Dr Tasnim Azim from Bangladesh told the session. About 15% of female IDUs in Bangladesh become pregnant within two years of developing a habit, Dr Azim said, adding that there were no antenatal clinics or services for female drug users.

While we eye the goal of Universal Access for 80% of IDUs, Bijaya’s plea ‘not give a false illusion’ serves as a grim reminder of the reality faced by those who need these services the most.

The social audit team completed its seventh day of audit despite being a stormy and rainy day in the areas. Rain cleared the sky, so did the process of social audit by uncovering the realities in the implementation of NREGS. Today gram pradhans cooperated fully in the audit, nevertheless at some places the 'cooperation' became hindrance and it affected the audit process as well. The gram pradhans are commendable for their constructive role and has helped in strengthening the democratic process. The audit was completed by the audit team in the gram panchayats of Arairr Kalaa, Mahendra, Shirsh Kanhar, Mawai Brahmnaan, Tajpur, Amethan Gadhi, Miyaganj, Sarai Chandan, Lag Lesaraa, and Kotraa.

The villagers narrated the sufferings in the implementation of NREGS to the audit team as soon as it arrived. The laborers of panchayats - ShirshKanhar, VawaiBrahmnan and Tajpur complained that they have to pay for the photo which is already prepaid by the NREGS. Ramchandra son of Paggal of Miyaganj panchayat is shown in the records to have worked for 71 days whereas he has worked and was paid for only 8 days. His site of work is shown in the records as connecting road construction and planting but the audit team found not even a trace of such developmental work.

When audit team reached Muzaffarpur Sarra the representative of gram prahdan participated was presenet throughout the audit process, however it generated apprehension among the villagers. Only 5 job cards were presented to verify by the team from a count of 487. It was obvious to the team that the villagers were afraid to tell the truth in the presence of the representative of the pradhan. When the team decided to look for the pradhan, they were informed that he is gone to open accounts for the laborers. Similarly in Saramba the audit team were refrained from verifying any job cards and were informed that the padhan is holding all the job cards. Similarly, in Mahendra village panchayat the plantation work shown in records do not even exist on ground.

As the rains after heavy storm cleared the villagers of Miyanganj block are hopeful for the positive changes in near future. The social audit team is able to complete the seventh day successfully with the help of public support and awareness.

Dr Sandeep Pandey

[Author is a noted social activist, recepient of Ramon Magsaysay Award (2002) for emergent leadership and heads National Alliance of People's Movements (NAPM) in India]

Up till now there was a situation of conflict and palpable tension between the Pradhans and the citizens' groups conducting the social audit of the National Rural Employment Guarantee Scheme (NREGS) in Miyaganj block, Unnao district. However today surprisingly the tension dissipated after yesterday's dialogue with the Pradhans explaining that the social audit is not to instigate any legal action against them but to enforce all the provisions of NREGS and empower people's rights in the democracy. The pradhans cooperated in the social audit today.

The social audit went ahead in a normal routine way today without any opposition in Himmatkhera, Ahra Dadia, parenda, Miyaganj, Salempur, Makhdoompur Sah, Mahendra, Nauhai, Buzurg, Pathakpur and Purwa Gram panchayats.

The block development officer (BDO) had earlier issued a letter on 13 May 2008 asking Pradhans to cooperate with the social audit. Pradhans had then filed a writ petition in the high court on which they did get a stay order. Despite of this stay order, the Pradhans decided to participate in the social audit and cooperate which is a remarkable achievement of democracy and re-instills our faith in people's rights.

In Gram panchayats Himmat Khera and puran Khera, social audit exposed gross irregularities in what was stated in the muster rolls and job cards and what was verified on the ground. For instance, in Puran Khera, the muster rolls and job cards show a road built from a school to durga maurya's farm, of the following dimensions: length 1350 feet, height 3 feet, and width 20 feet. However upon measurement, the social audit team found the road of following dimensions: length 560 feet, height 1 foot and width 20 feet.

Another example is of a labourer Gaya Prasad (son of Ram Shankar) whose job card shows that he got 10 days of work each in 2006-2007 at beer baba talab and plantation work. However he testified to the social audit team that he didn't do a single day's work at either of these places. Also the job card of Gaya Prasad shows that he has got 64 days worth of work till now, however in reality he has worked only for 16 days.

The social audit team witnessed another incident of Pradhan's terrorizing the people in Nauhai buzurg gram panchayat. Initially the labourers in this village had stated to the social audit team that there were discrepancies in the job cards and muster rolls but upon being terrorized by the Pradhan's men, most of them promptly changed their testimony. Some irregularities the team discovered included the case of Munna (son of Jiya Lal) whose job card shows that he had got work for 14 days on the link road but in reality he has worked only for 6 days. Similarly his job card shows 12 days worth of work for the plantation, but in reality he worked only for 2 days.

Up till now the stiff resistance Pradhans were confronting the social audit team, waned away eventually under mounting public pressure and resolve to conduct the social audit and exercise their right bestowed to them by existing policies.

Photo by bobbyramakantBy International Network of People Who Use Drugs, “Asia and the Pacific Region”

January 2008, India

Besides being the world’s largest producer of opiates and other drugs such as Amphetamine type substances (ATS), the Asian and the pacific region is home to the largest number of drug users. Although evidence-based, cost-effective approaches are endorsed and promoted by various agencies people who use drugs in the region continue to be oppressed by discriminatory government policies and non-evidence based ‘solutions’ to drug use, such as imprisonment and compulsory detoxification and rehabilitation. Without taking into consideration the socio-economic factors underpinning drug use in the region, people who use drugs will continue to be harassed, marginalised and discriminated against, stereotyped as dangerous and imprisoned.

The constant oppression, persecution and human rights violation contributes to HIV and hepatitis vulnerability of people who use drugs, particularly those who inject. In Asia, up to 89% of new HIV and 92% of hepatitis C infections are occurring among injecting drug users (IDUs). On average IDUs account for 30-50% of new HIV infections and 40-60% of the IDU population is estimated to be living with hepatitis C virus (HCV) as well. Even though it is obvious that drug users’ vulnerability to and experience with HIV and HCV make them one of the most important constituents in responses to HIV and HCV in Asia and the Pacific, the level of harm reduction, treatment, support services available as well as involvement of that particular community continues to be grossly insufficient.

If Asian and the Pacific governments, civil society, health care providers and other stakeholders are serious about halting the HIV/HCV epidemic, purposeful attention and action must be given to ensure evidence-based and non-oppressive approaches to address the needs and high vulnerability of the IDU population in Asia and the pacific. Policies on drug control need to be harmonized with HIV and HCV prevention, treatment, care and support efforts and standards of services for harm reduction would also be required in order to have an enabling environment for sustainable service delivery.

In this context, WE, the people who use drugs in Asia and the Pacific, thereby:

Call on governments, various agencies, bi- and multilateral organisations, civil society organisations (CSOs) and the general public to support in:

* Empowering our communities to advocate and protect our rights and to facilitate meaningful participation in decision making on issues affecting us;
* Promoting a better understanding of current drug policies that negatively impact on the lives and rights of people who use drugs, their families and communities;
* Acknowledging and enhancing our knowledge and skills to educate and train others, particularly our peers and members of our community;
* Advocating for Universal Access to harm reduction, HIV/HCV treatment and care programmes, including access to evidence-based and effective drug treatment, appropriate medical care, safer consumption equipment, safe disposal of syringes and needles, up-to-date information about drugs and their effects, and safer facilities for practicing harm reduction;
* Protecting and eexercising our right to evidence-based information on various drugs including their side effects and complications, access to equitable and comprehensive health and supportive social services, safe and affordable housing and meaningful employment opportunities;
* Establishing specifically designed program to address the issues of women who use drugs and allocate enough resources to ensure programs are sustainable while actively promoting their meaningful full participation in all policy, program design and implementation process.
* Supporting local, national and regional networks of people who use drugs are incorporated at all levels of decision-making and equitably remunerated for their contributions;
* Challenging laws, policies and programmes that disempower, oppress and prevent us from leading healthy and positive lives;
* Distinguishing drug dealers from people using drugs who need support, care and treatment instead of oppression and prosecution;
* Providing easy access to affordable antiretroviral medicines including second and third line treatments, TB and HCV treatment for all who need them; if necessary by enacting intellectual property laws to protect the rights of developing countries to implement the safeguards enshrined in the TRIPS agreement and Doha Declarations such as Compulsory Licenses, as endorsed by the 2007 WHO General Assembly;
* Advocating for development and adherence to harm reduction service delivery such as NSP, OST, residential care, ARV/HCV treatment etc.

Affirm our duties and responsibilities as responsible citizens in:

* Contributing to collective efforts against the HIV and HCV epidemics in Asia and the Pacific, including HIV and HCV prevention, and care and support of those already infected and affected;
* Seeking understanding of issues, challenges and needs of drug users in Asia and the Pacific;
* Promoting tolerance, cooperation and collaboration; fostering a culture of inclusion and active participation;
* Respecting the diversity of backgrounds, knowledge, skills and capabilities, and cultivating a safe and supportive environment within the drug user community regardless of the types and routes of drugs consumption;
* Supporting, strengthening and encouraging the development of organizations for people who use drugs in communities/countries where they do not exist.

State our position that:

* The most profound need to establish a network of people who use drugs arises from the fact that no group of oppressed people ever attained liberation without the empowerment and involvement of those directly affected;
* Through collective action, we will challenge existing oppressive drug laws, policies and programmes and work with government and our constituents to formulate evidence-based drug policies that respect human rights and dignity of people who use drugs.

Issued at the First Asian Consultation on the Prevention of HIV Related to Drug Use. Goa, India on 31 January 2008.

Two local residents of Miyaganj block, Unnao district (UP, India) Virendra Singh and Yashwant Rao, had written to Block Development Officer (BDO) of Miyaganj seeking support to conduct the social audit of NREGS. The BDO wrote to every pradhan in this block seeking their cooperation in submitting all documents pertinent to the NREGS. On behalf of all pradhans, the president of the Pradhans' association, had filed a writ petition in the High Court demanding a stay order, which she did get on 22 May. It was this stay order which had spread the perception that the pradhans have obtained a stay against the social audit.

However the people's movements conducting the social audit have taken a position that the citizens are given the legal right to conduct a social audit of NREGS related work under the National Rural Employment Guarantee Act (NREGA). Conducting this social audit doesn't depend upon the support or permission of the BDO. The documents needed to conduct a social audit have already been obtained under the Right to Information (RTI) Act 2005. Therefore the social audit can be conducted even without the support of pradhans by directly talking to the labourers/ workers and verifying the work done under NREGS on-site. The people have decided to exercise this right and conduct the social audit in Miyaganj.

On fifth day of social audit, the work was paralysed by the ruckus created by the goons sent by pradhans in four gram panchayats, namely - sindhari khurd, makhdoompur shah safi, deepagarhi and mustafabaad. These goons of Pradhans were drunk, and wielded lathis (batons) to terrorise the citizens conducting the social audit. However by evening the resistance withered away and the people could resume the social audit process.

In presence of BDO, it was clarified to the pradhans that the motive of conducting a social audit was not to instigate some action on pradhans but to fully implement all the provisions of the NREGA. The real power in democracy rests with the people and therefore the struggle to safeguard, protect and exercise the rights of people to conduct a social audit, is fundamentally an empowerment process strengthening the rights of the most disadvantaged.

Most of the pradhans have understood the main objectives of the NREGS social audit, and expressing their respect to democracy and the rights of the people, they have assured of their cooperation in the audit.

Clarifications:- In gram panchayat Nurulla Nagar, earlier it was reported that the photocopy of the bill shows a purchase of 3000 bricks for Rs 74,481. Today the gram pradhan showed the original receipt and clarified that while doing the photocopy of the bill, the figure of '33,000' was copied as '3,000' because of a folded corner.- Earlier in social audit, gross inadequacies were reported from Gram Panchayat Aaseevan. The complete name of this gram panchayat is Aseevan Lok Man.

Dr Sandeep Pandey[Author is a noted social activist, recepient of Ramon Magsaysay Award (2002) for emergent leadership and heads National Alliance of People's Movements (NAPM) in India]-----------------------------------------------------

Pradhans and their people are blocking the social audit in Unnao. There are threats to lives of teams conducting audits (individual and collective threats) and one team was chased by pradhan's people (who were ostensibly under the influence of alcohol) for more than one kilometer. The situation is on razor edge and there was a meeting with the 60 pradhans today evening. BDO and the officials are supporting the social audit bu pradhans have amassed resistance through the goons who are heavy handed. There is political pressure from MLA who phoned the BDO opposing the audit.

There are sufficient number of local rights campaigners and activists leading this audit including yeshwant Rao and Virendra Singh. Local wing of Bhartiya Kissan Union has also provided full support.

There are about 80 people divided in 10 teams conducting social audits. Villagers are not 100% responsive yet as the mass base is good but not as strong as in Hardoi. Villagers are coming forward and complaining of problems with job cards and wages.

I believe they are not seeking police protection yet as the police pressure will be temporary. The team is relying solely on building the public pressure for now.

Photo by ΟΆКІ Clinical trials have found that anti-HIV vaginal microbicide gel Carraguard is not effective, it was announced last week.

The trial results are the latest in a string of disappointments for people hoping to develop a cream or gel to help protect women against the transmission of HIV through sex.

Carraguard, made from carrageenan seaweed, has been deemed safe by the US Food and Drug Administration “for oral and topical use”. During clinical trials however, just 10% of female participants used the gel as instructed, rendering the product ineffective.

All trial participants received information on HIV, safer sex practices and how to reduce the risk of contracting a sexually transmitted infection (STI). Care and support services were provided to female participants, who were given male condoms as well as an inactive gel or placebo.

But the women used the gel less than half the number of times they had sex, calling the practicality of microbicides into question. While the development of anti-HIV creams and gels is seen as a key step towards empowering women in the fight against HIV, the use of such preventative measures requires the cooperation of a woman’s partner.

Gender inequalities prevent many women from being able to protect themselves against HIV. Millions of women lack the social or economic power to insist on preventative measures such as condoms, abstinence or monogamy. So while the development of microbicides is appealing in theory, in reality, and during clinic trials, the gels are not proving effective.

Women who took part in the Carraguard trials were expected to use the gels during social interactions that allowed them little power to negotiate issues related to sex and their sexuality. Outside the laboratory, other social situations further reduce the women’s likelihood of using the product.

Millions of women live in societies that permit them no role in sexual decision-making, condone male infidelity and assign the shame and stigma associated with infectious diseases to women.

Existing preventative strategies have largely failed to address this vulnerability, focusing on abstinence, mutual monogamy and male condom use, none of which are easily controlled by women.

Vaginal microbicides are also likely to fail until men understand and respect the need for women to protect themselves against HIV and other STIs. Not only do women need preventative options that they can choose to use freely but the gender inequalities that make it harder for women to insist on safer sex must be addressed.

Hopefully delegates at the International Microbicides Conference 2008 in Delhi, India will address these issues and can help produce effective strategies to reduce gender inequalities as well as promising microbicide products.

On the second day of social audit of National Rural Employment Guarantee Scheme (NREGS) by a group of citizens in the Miyaganj Block of Unnao District the Gram Pradhans continued to create trouble.
They are feeling quite frustrated that their attempt to scuttle the social audit process by spreading a rumour that they had obtained a high court stay against the social audit did not work.

Today a number of them sat at the Block office grumbling and abusing the social audit team in private conversations. Sudeep Singh, the son of Gram Pradhan of Virugadhi, Shukrapal Singh, barged in with a group of his friends, all armed with lathis, while the social audit team was having lunch and even tried to drive them away from the village.

However, the social audit team stood their ground and ultimately when he was warned that a FIR could be lodged against him, Sudeep Singh tendered a written apology. The ten social audit teams continued to perform their work although not in the most congenial atmosphere.

In village panchayat Korari Khurd the administration had organized an open meeting of the Gram Sabha today. The District Panchayati Raj Officer came to attend this meeting from Unnao. Coincidently one of the social audit teams happened to be in this panchayat today.

It encouraged a few people to speak out about the irregularities in the implementation of NREGS in their panchayat. Sachin s/o Shiv Prasad has been shown to have worked for 38 days in tree plantation work on his Job Card No. 422 whereas in reality he has not worked at all. The Job Card No. 52 of Ram Sewak s/o Jhuri shows 30 days of work whereas Ram Sewak has actually put in 14 days of work only. Durga's Job Card No. 442 shows 14 days of work performed whereas she has worked only for half a day. But when these people tried to present their case, their Job Cards were snatched by the Pradhan's men and they were dragged out of the meeting. All this happened while the DPRO was present and the Gram Pradhan was sitting next to him in the open meeting.

Today some villagers from Makhbool Kheda approached the temporary office of the social audit set up at the Block office to register their complaints. Sheetla s/o Jagannath presented his Job Card which reflects total work of 42 days. The Job Card of Matadin s/o Joddha shows 74 days of work. In reality both of them have not even worked for a single day. Shaym Lal s/o Haridas has been shown to have worked on a pond deepening work for 7 days whereas in reality he worked only for two and a half days.

In village panchayat Aaseewan Lok Man a number of people have been shown to have worked for 8 days on a drain digging work. However, Shankar s/o Neelkanth, Shivdeen s/o Chote Lal, Chote Lal s/o Deena, Ramrati w/o Shankar, etc., people whose names appear on the muster roll testified that they have not worked for a single day on this particular work.

It must be realized that exaggeration of number of days of a worker on the muster roll not only means embezzlement of funds but also reduction of number of exaggerated days from the 100 days of legal guarantee of employment under the NREGA, 2005. This irregularity ought to be treated as a violation of the law.

Photo by ricardo.martinsThe latest disappointment for scientists working to develop an effective microbicide came just days before the International Microbicides Conference 2008 in New Delhi, when another anti-HIV vaginal gel failed to prove effective against the disease.

Microbicide advocates around the world voiced their concern over the potential for the failure to cloud the need for more effective HIV prevention measures for men and women.

But the messages from the February 24–27 New Delhi conference were positive and clear with delegates calling for an end to the gender inequalities and power imbalances that continue to put many women at risk of contracting sexually transmitted infections (STIs) such as HIV.

India’s Union Health and Family Welfare Minister, Dr Anbumani Ramadoss told conference representatives, “AIDS in India is not only a health issue, it is a social issue, it is an economic issue.”

“Millennium Development Goals speak about promoting gender equality, empowerment and improved maternal health to combat HIV. It will be very difficult to achieve the … goals if the current trend of increasing HIV infections in women continues,” Dr Ramadoss said.

“Although the HIV prevalence in India is 0.36%, the latest antenatal figures are 0.8%, which shows that women are vulnerable. Studies done in Chennai and Pune have shown that more than 90% of women infected are married, monogamous women who don’t perceive their husband as a threat. Condom use reported among these women is only 8%.”

This year marked the first time the conference had been held in Asia and more than 1300 delegates attended to discuss promising microbicides in the research pipeline, along with global efforts to accelerate research and development and the need to reduce the gender inequalities that put women at risk.

The development of microbicides is seen as a key to empowering women to protect themselves from HIV. Women are biologically more vulnerable to the transmission of STIs and many cultural and economic factors compound this vulnerability.

Millions of women live in societies that permit them no role in sexual decision-making, that condone male infidelity and assign the burden of shame and stigma associated with infectious diseases to women.

Former Director General of the Indian Council of Medical Research, renowned scientists and patron of MRAI Dr Nirmal K Ganguly told conference delegates that despite a number of setbacks, microbicides could be useful to many women and that four candidate products were “entering into important stages of clinical trials in India.”

“We need more work on basic research, both for microbicides and vaccines,” Dr Ganguly said before highlighting the need for further advocacy and the involvement of communications experts in the drive for the use of microbicides.

“I attended a symposium at a Boston university where the major people in the public health area were a linguist, a musician and a filmmaker because they were the people who had the power to communicate in language which was understood by the people for whom it was meant,” Dr Ganguly said.

--------------------------

To listen to the podcast of the opening ceremony, with the plenary presentations made by Union Health Minister of India Dr Ramadoss, click here

Gram Pradhans, the elected representatives at the village level, attempted to disrupt the ongoing social audit in Unnao. This social audit is being carried out by the citizens on the development work done under the National Rural Employment Guarantee Scheme (NREGS).

The Miyaganj block development office had earlier provided documents related to NREGS after one and a half years struggle at UP State Information Commission under Right to Information Act. These documents are being verified by the citizens themselves in the ongoing social audit.

The Gram Pradhans had spread the rumour that high court has granted a stay-order against the social audit. In many Gram Panchayats including Bhadua, Barha Kala, Kulha Ataura and Korari khurd, the social audit work remained suspended for few hours owing to the rumour.However when people demanded a copy of the High Court stay-order, the Gram Pradhans couldn't produce any copy. The people thereby decided that unless they get to see a copy of the stay order, they will not stop the social audit.

The resistance put up by the Gram Pradhans in some gram panchayats on the pretext of a rumour to disrupt the social audit, slowly started giving way to the mounting public pressure to continue the social audit.Only in one gram panchayat, Korari Khurd, the social audit remained paralyzed for the entire day because of never-ending arguments between the gram pradhan and the social audit team. Interestingly enough, the people we could speak to in this village, reported that their 'job cards' are with the Gram Pradhan. Job cards under NREGS should be with the worker at all times.

Gram pradhans are resistant to the social audit because it will potentially expose the gross-irregularities, corruption and in-discrepancies in the work done under NREGS. NREGS is playing a phenomenal role in empowering the weakest sections of the society to hold the 'mighty' accountable.Many gram pradhans have accepted verbally that irregularities have taken place in the NREGS work. It is only a matter of few days now when findings of the social audit will expose them all in a public hearing on 28 May.

It is evident from the stiff resistance of Gram pradhans to the citizen's social audit that despite of the legal provisions under National Rural Employment Guarantee Act (NREGA) and Right to Information Act (RTI) that empowers a common citizen with the right to hold those-in-power accountable and increases transparency, the ruling class is trying unsuccessfully to derail the process because of its vested interest.

The social audit team met 108 people in Gram Panchayat Kulha Ataura who wanted to get work under NREGS but their job cards were not made. Annat Ram (son of Bhola) said that he had submitted his photograph 3 times for the job card in past two years and the job card was finally delivered to him this morning. Upon further investigation, the social audit team discovered that just few hours earlier that morning, most of the job cards were distributed in this village. These job cards already show an entry for 10 days work to dig a water body 'Chaptenwa Talaab' further deep.Ram Baran (son of Madhav) said that although he didn't get a single day of work, still his job card shows 24 days of work. Muster Roll obtained through RTI application, didn't show his name even.

The job card of Bhaiya Lal (son of Ram Prasad) shows 68 days of work although in reality he got work only for 4 days. About 65 people in this gram panchayat are below the poverty line (BPL), possessing a BPL ration card to get food grains and sugar from the public distribution system (PDS). But in the last 5 years, none of these 65 people got even a single grain from PDS. Antyodaya ration cards do show some distribution but in reality it hasn't taken place.

Despite of the 'High Court stay order' rumour and stiff resistance put up by the Gram Pradhans and other vested interests, it gives me hope that the steely resolve of the people to conduct the social audit related to their own development and welfare, could prevail. The social audit, as expected, is exposing gross-irregularities.

Dr Sandeep Pandey

[Author is a noted social activist, recepient of Ramon Magsaysay Award (2002) for emergent leadership and heads National Alliance of People's Movements (NAPM) in India]Published in